Influence of the timing of cardiac catheterization and the amount of contrast media on acute renal failure after cardiac surgery.

Postoperative acute renal failure (ARF) is not uncommon after cardiac surgery and after angiography. However, limited information exists regarding the influence of the interval between cardiac catheterization and subsequent cardiac surgery and amount of contrast agent used during this procedure on the occurrence of postoperative ARF. Data for 423 consecutive adult patients who underwent elective cardiac surgery after cardiac catheterization were examined retrospectively. The influence of interval between cardiac catheterization and cardiac surgery on postoperative ARF (defined as postoperative serum creatinine > or =2 times baseline and >2 mg/dl and/or need for renal replacement therapy) was evaluated using multivariable logistic regression. ARF occurred in 24 patients (5.7%). Median time to angiography was 2 days (interquartile range 1 to 4.5), and median dose of contrast used was 1.36 ml/kg (interquartile range 1.12 to 1.69). Surgery on the day of cardiac catheterization was independently associated with increased risk of ARF (adjusted odds ratio 3.1, 95% confidence interval 1.1 to 8.8). This risk of ARF was highest in patients who underwent surgery on the same day as angiography and with a dose of contrast higher than median (14.6%) and lowest when surgery was delayed beyond 1 day of angiography and contrast dose was median or less (2.4%; adjusted odds ratio for same-day surgery and dose higher than median 4.2, 95% confidence interval 1.2 to 14.2). Cardiac surgery performed on the day of cardiac catheterization and higher dose of contrast agent used were both independently associated with increased risk of postoperative ARF. In conclusion, these findings suggest that delaying cardiac surgery beyond 24 hours of exposure to contrast agents (when feasible) and minimizing the use of these agents have significant potential to decrease the incidence of postoperative ARF in patients undergoing elective cardiac surgery.

Cyclosporine A in Reperfused Myocardial Infarction: The Multicenter, Controlled, Open-Label CYCLE Trial.

BACKGROUND: Whether cyclosporine A (CsA) has beneficial effects in reperfused myocardial infarction (MI) is debated. OBJECTIVES: This study investigated whether CsA improved ST-segment resolution in a randomized, multicenter phase II study. METHODS: The authors randomly assigned 410 patients from 31 cardiac care units, age 63 ± 12 years, with large ST-segment elevation MI within 6 h of symptom onset, Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 to 1 in the infarct-related artery, and committed to primary percutaneous coronary intervention, to 2.5 mg/kg intravenous CsA (n = 207) or control (n = 203) groups. The primary endpoint was incidence of ≥70% ST-segment resolution 60 min after TIMI flow grade 3. Secondary endpoints included high-sensitivity cardiac troponin T (hs-cTnT) on day 4, left ventricular (LV) remodeling, and clinical events at 6-month follow-up. RESULTS: Time from symptom onset to first antegrade flow was 180 ± 67 min; a median of 5 electrocardiography leads showed ST-segment deviation (quartile [Q]1 to Q3: 4 to 6); 49.8% of MIs were anterior. ST-segment resolution ≥70% was found in 52.0% of CsA patients and 49.0% of controls (p = 0.55). Median hs-cTnT on day 4 was 2,160 (Q1 to Q3: 1,087 to 3,274) ng/l in CsA and 2,068 (1,117 to 3,690) ng/l in controls (p = 0.85). The 2 groups did not differ in LV ejection fraction on day 4 and at 6 months. Infarct site did not influence CsA efficacy. There were no acute allergic reactions or nonsignificant excesses of 6-month mortality (5.7% CsA vs. 3.2% controls, p = 0.17) or cardiogenic shock (2.4% CsA vs. 1.5% controls, p = 0.33). CONCLUSIONS: In the CYCLE (CYCLosporinE A in Reperfused Acute Myocardial Infarction) trial, a single intravenous CsA bolus just before primary percutaneous coronary intervention had no effect on ST-segment resolution or hs-cTnT, and did not improve clinical outcomes or LV remodeling up to 6 months. (CYCLosporinE A in Reperfused Acute Myocardial Infarction [CYCLE]; NCT01650662; EudraCT number 2011-002876-18).

Prolonged double antiplatelet therapy in a cohort of "de novo" diabetic patients treated with drug-eluting stent implantation.

Diabetes mellitus (DM) accounts for >25% of all percutaneous coronary interventions. In patients with DM, drug-eluting stent implantation is associated with a reduced risk of restenosis and target lesion revascularization. However, concern has been raised about the incidence of late and very late stent thrombosis and the increased mortality rate, mostly after thienopyridine withdrawal. We evaluated the long-term prognostic effect of thienopyridine discontinuation after drug-eluting stent implantation on the subsequent occurrence of stent thrombosis and all-cause death among a cohort of high-risk "de novo" diabetic patients. From May 2002 to December 2005, 542 consecutive patients with DM underwent drug-eluting stent implantation at 2 hospitals in Milan, Italy. For study purposes, only the 217 patients who had not previously undergone percutaneous or surgical revascularization were considered in the final analysis. The follow-up time was curtailed at 3.5 years. Detailed information about dual antiplatelet therapy (DAT) were collected for all patients included. Of the 217 patients, 15 died (6.9%); in 9 cases, the cause of death was cardiac (4.1%). The incidence of cumulative stent thrombosis was 4.6% (10 patients); 3 stent thromboses were early (1.38%), 5 late (2.3%), and only 2 were very late (0.9%). Of the 10 cases of stent thrombosis, 5 were definite and 5 were probable. Most (80%) of the stent thromboses occurred within the first 6 months during DAT. The median duration of DAT was 420 days (interquartile range 350 to 859). DAT discontinuation was the only independent predictor of the follow-up events (hazard ratio 20.42, 95% confidence interval 4.99 to 83.62). In conclusion, DM remains an independent adverse factor on clinical outcome. In this setting, prolonged DAT, even beyond that recommended in the guidelines, might be beneficial.

Stent-graft treatment of late stenosis of the left common carotid artery following thoracic graft placement.

We report the case of a patient with subtotal occlusion of the origin of the left common carotid artery (CCA) following thoracic graft placement. Retrograde endovascular placement of a stent-graft by minimal cervical access was undertaken to repair the occlusive lesion of the left CCA and prevent future complications of endoluminal thoracic reconstruction. The retrograde endovascular repair of CCA lesions, as other authors have already suggested, may be the treatment of choice in "high-surgical-risk" patients. In these cases where the ostium of supra-aortic trunks is compromised following thoracic aorta stent-graft migration, endoluminal placement of a stent-graft in the CCA can guarantee both maintenance of carotid flow and thoracic stent-graft fixation.

Endovascular repair of thoracic aortic disease with the EndoFit stent-graft: short and midterm results from a single center.

PURPOSE: To analyze the outcomes of endovascular treatment of thoracic aortic pathologies performed at a single center with the EndoFit thoracic stent-graft system. METHODS: From January 2002 to January 2007, 41 patients (33 men; mean age 69.3+/-9.7 years, range 48-84) were treated for thoracic aortic disease with the EndoFit stent-graft system. Patient data were retrieved from a retrospective review of hospital records. Indications for treatment were progression of aneurysm size in atherosclerotic aneurysms (n = 24, mean aneurysm diameter 7.19+/-1.48 cm), acute contained aortic rupture (n = 5), aortic dissection (n = 6), penetrating atherosclerotic ulcers (n = 4), post-traumatic pseudoaneurysm (n = 1), and post coarctation repair aneurysm (n = 1). RESULTS: The EndoFit stent-graft was successfully deployed in all 41 patients. The in-hospital and 30-day mortality rate was 7.3% (3 patients). Three (7.3%) postoperative endoleaks were recorded: a proximal type Ia and a distal Ib both resolved spontaneously at 1 and 3 months, respectively. The third patient had a persistent type Ia endoleak; conversion was necessary after 1 year. There was only 1 case of spinal ischemia, with consequent lower extremity weakness; no paraplegia was observed. During a mean 24.8-month follow-up, 2 secondary type Ia endoleaks were treated with additional stent-grafts. There were 7 (17%) deaths during follow-up. At 2 years, overall patient survival by Kaplan-Meier analysis was 70%; aneurysm-related survival was 89%. CONCLUSION: Endovascular treatment of vascular disease involving the descending thoracic aorta can be safely performed with the EndoFit thoracic stent-graft system.

Clip-based arterial haemostasis after antegrade common femoral artery puncture.

BACKGROUND: Given the frequent involvement of infra-popliteal arteries, an ipsilateral antegrade common femoral artery puncture (ACFAP) is usually preferred to a contralateral retrograde femoral access for percutaneous transluminal angioplasty (PTA) in patients with critical limb ischemia (CLI). Because of the frequent difficulty to get a sufficient manual pressure on the puncture site, ACFAP is burdened by a high number of bleeding local complications, including retroperitoneal haematoma. We report a series of patients who consecutively received a clip-based arterial closure device after ACFAP and ipsilateral PTA for CLI. METHODS: Thirty patients (73+/-6 years; 18 men; 100% diabetes) admitted to our hospital because of CLI consecutively underwent peripheral PTA after an ACFAP and received a clip-based arterial closure device. Time to haemostasis was defined as the interval elapsed between clip deployment and first observed haemostasis. All patients were mobilized after 6 h. Follow-up was 30 days. RESULTS: All patients were on double anti-platelet therapy. At the end of the procedure, Activation Clotting Time was 226+/-37 s. Procedural success in delivering the clip was 100%. Time to haemostasis was 21+/-19 s. No major local vascular complications and in particular no retroperitoneal bleeding were documented. All patients could be discharged within the following 3 days. No major complications were noted during a 30 days follow-up. CONCLUSIONS: The use of a clip-based arterial closure device after ACFAP for peripheral PTA in CLI seems to be safe and effective.

Antegrade access in a stented common femoral artery: feasible but with a real bleeding risk.

Antegrade femoral artery access is often used for diagnostic and interventional purposes in patients with critical limb ischemia, given its potential advantages in terms of visualization and back-up. However, it may be associated with an increased risk of local vascular complications, especially in the presence of common femoral artery atherosclerosis. We hereby report a case of antegrade femoral access in a previously stented common artery, which enabled successful recanalization of a totally occluded superficial femoral artery. Despite the procedural success, retroperitoneal bleeding occurred after sheath removal, which was nonetheless effectively managed with prolonged balloon inflations by means of contralateral femoral artery access. This clinical vignette, the first to date to report on antegrade access in a stented femoral artery, supports its feasibility despite the presence of a real bleeding risk.

Angioseal use after antegrade femoral arteriotomy in patients undergoing percutaneous revascularization for critical limb ischemia: a case series.

Antegrade femoral artery access is commonly used for percutaneous transluminal revascularization of ipsilateral lower limbs in patients with critical limb ischemia. While hemostasis at the end of the procedure can be achieved by manual compression, this may lead to an increase in local vascular complications. Femoral artery closure devices, such as the Angioseal collagen plug and anchor device, have been approved and shown of benefit after retrograde femoral artery catheterization. To date, there are however no data on the use of such arteriotomy closure device after antegrade femoral access. We hereby report a case series of five patients in whom Angioseal was successfully used after antegrade femoral puncture and below-the-knee percutaneous transluminal angioplasty. In all cases the device enabled immediate and complete hemostasis without major complications, despite the intense antithrombotic regimen, including heparin, aspirin, and clopidogrel in all patients, as well as glycoprotein IIb/IIIa inhibitors (in two patients) and fibrinolytic therapy (in one).

Chronic inflammation and increased arterial stiffness in patients with cardiac syndrome X.

AIMS: Endothelial dysfunction and subangiographic atheroma have been reported in patients with cardiac syndrome X (CSX) but little is known regarding chronic inflammation and reduced arterial distensibility as pathogenic mechanisms. We assessed whether markers of inflammation and arterial distensibility differ in CSX patients compared to control subjects. METHODS AND RESULTS: We studied 30 consecutive CSX patients (mean age 57+/-6 years, 25 women) and 30 healthy controls (mean age 54+/-8 years, 25 women). High sensitivity C-reactive protein (hs-CRP) levels were significantly higher in patients with CSX compared to controls (2.6 [1.7-4.5] vs 1.5[0.7-2.7] mg/l, P=0.02). Hs-CRP levels correlated with carotid intima-media thickness (IMT) (Spearman's rho=0.51; P=0.013). CSX patients also had significantly increased mean IMT values than controls (P<0.0001). Arterial stiffness and elastic modulus were also significantly increased in CSX patients compared to control subjects (P=0.04 and P=0.04, respectively). Distensibility tended to be lower in CSX patients than controls although this difference did not reach statistical significance. CONCLUSIONS: This study showed for the first time that compared to control subjects, patients with CSX have higher hs-CRP serum levels, increased mean common carotid artery IMT and increased arterial stiffness. The role of these abnormalities in the pathogenesis of CSX deserves investigation.

Axillary artery access for interventional procedures.

PURPOSE: To evaluate axillary artery access for the interventional treatment of carotid or splanchnic arteries that have angulated takeoff or complex anatomy when larger catheters (up to 9 F) are needed. TECHNIQUE: The axillary artery approach was used to treat the left internal carotid artery (ICA) in 3 patients (2 angulated takeoffs and 1 bovine arch) and a celiac axis aneurysm. An 8-F, 45-cm-long introducer sheath was inserted for the carotid procedures, whereas a 9-F, 90-cm sheath was chosen for the celiac aneurysm. Cerebral protection and stenting were successfully performed in all carotid patients; an 8x40-mm stent-graft was implanted to exclude the celiac artery aneurysm. An 8-F vascular closure device was used in the axillary arteries; hemostasis was immediate, and no hematoma or other complications were recorded in follow-up. CONCLUSIONS: This preliminary experience revisits the axillary approach as an alternative access route for interventional procedures. In association with a vascular closure device, this approach should be considered as a useful and safe option for those interventional procedures in which larger sheaths or catheters are required to cope with difficult arterial anatomies.